Provider Demographics
NPI:1952682197
Name:WHITE, AVERY (LMT)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 203894
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78720-3894
Mailing Address - Country:US
Mailing Address - Phone:512-850-7148
Mailing Address - Fax:
Practice Address - Street 1:811 W SAINT JOHNS AVE
Practice Address - Street 2:UNIT 2105
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-2387
Practice Address - Country:US
Practice Address - Phone:512-850-7148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT104847225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist